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Plantar Fasciitis: Chronic Plantar Heel Pain

Chronic Plantar Heel Pain (CPHP), plantar fasciitis, jogger's heel... call it what you will, persistent heel pain is one of the most common sports injury affecting runners.

What is the plantar fascia and what is its function?

Your Plantar Fascia is a thick fibrous band of connective tissue similar to a tendon and ligament, originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes.

Your Plantar Fascia acts as a passive limitation to the over flattening of the arch of the foot, and is also an active sensory structure providing the brain with feedback about the position of the ankle and foot.

What is Plantar Fasciitis or Chronic Plantar Heel Pain (CPHP)?

The common and frequently used term Plantar Fasciitis refers to the long held assumption that it is the direct result of an inflammatory process. However this belief has been challenged, and it has been found that the condition is not primarily inflammatory and is in fact the result of degenerative changes at the origin or enthesis of the Plantar Fascia at the heel, including a deterioration of collagen fibres, increased secretion of ground substance proteins and increased vascularity (Jarde et al., 2003; Lemon et al., 2003). Therefore from this point forward I’ll refer to this condition as Chronic Plantar Heel Pain (CPHP).

Chronic Plantar Heel Pain usually presents as pain under your heel or in the arch of your foot in the morning or after resting.

Quite often your symptoms will be worst with the first steps you take in the morning and improves with activity, as it warms up.

The prevalence in the general population is estimated to range from 3.6% to 7% (Dunn et al., 2004; Hill et al., 2008), whereas plantar fasciitis may account for as much as 8% of all running related injuries. (Lysholm & Wiklander, 1987; Taunton et al., 2002).

What causes Chronic Plantar Heel Pain and what are the risk factors?

Activity: Sports that place excessive stress on the heel and attached tissue e.g. running, ballet and aerobics. Especially if you have tight calf muscles or a stiff ankle/big toe from a previous ankle sprain/injury. This may limit ankle movement and leave you at greater risk of developing CPHP.

Weight: Carrying around extra weight increases the strain and stress on your plantar fascia.

On your feet: Having a job that requires a lot of walking or standing on hard surfaces ie factory workers, teachers and waitresses.

Footwear: Wearing shoes with poor support increases the load through the Plantar Fascia.

Your foot structure: flat feet or high foot arches where changes in the arch of your foot changes the shock absorption ability and can stretch and strain the plantar fascia, which then has to absorb the additional force.

Weak Intrinsic Foot Muscles and poor foot control: Muscle fatigue, weakness and poor control can overload your plantar fascia and cause injury.

Reduced Ankle Mobility (Dorsiflexion) and great toe mobility (Dorsiflexion) can increase the loading of the Plantar Fascia.

The presence of a calcaneal spur (heel spur) can lead to increased risk of developing CPHP and can be confirmed by X-Ray.

Body mass index (BMI) in the general population and the presence of a calcaneal heel spur are the two factors found to have an association with plantar fasciitis according to a Cochrane review by Irving (2006). A BMI of 25-30 kg/m2 approximately doubles the occurrence of CPHP, and it triples if passive ankle joint dorsiflexion is less than 10°. It increases by 3.6 times in weight bearing occupations (Sahin et al, 2010).

How is CPHP assessed?

At Recover Sports Medicine, our highly trained physiotherapists and podiatrists have the ability to diagnose CPHP, through a specific musculoskeletal and biomechanical assessment. Your Physiotherapist or Podiatrist may refer you for an X-Ray to help identify a heel spur or an ultrasound scan or MRI to identify a Plantar Fascia Fascia tear, calcification or the degree of thickening at its attachment into the heel.

Your treating practitioner may utilise our state of the art Bio-Motion Lab to further assess your running technique and functional movement patterns i.e. squat, lunge, jump and hop.

Please follow the link below for more information on our Bio-Motion Laboratory.

http://www.recoversportsmed.com.au/bio-motion-lab.html

From this thorough assessment our practitioners can usually provide you with a clear diagnose, determine the cause of your symptoms and create a treatment plan to not only resolve and reduce your pain and symptoms, but address the cause to prevent it from reoccurring in the future.

Treatment

Treatment of your Chronic Plantar Heel Pain, may consist of, but is not limited to the following:

Low Dye Taping:

A study by Radford et al (2006) was able to demonstrate that when used for the short-term treatment of plantar heel pain, low-Dye taping provides improvement in 'first-step' pain compared with a sham intervention after a one week. The aim of Low Dye taping is to support the arch of the foot, improve foot posture and reduce stress on the foot and lower limb during activity.

Custom Foot Orthoses:

Custom foot orthoses have been shown to be effective in both the short-term and long-term treatment of pain. Improvements in function, foot-related quality of life, and a better compliance suggest that a foot orthosis is a good choice for initial treatment plantar fasciitis (Roos et al 2006). Upon review with our podiatrist, an assessment will determine the need and benefit of orthotic intervention. From this, custom orthotics can be made to assist your symptoms and improve your foot and lower limb biomechanics.

High Load Strength Training:

Recent research by Michael Rathleff and associates has highlighted the benefit of high load strength training. Rathleff concluded in his study that ‘a progressive exercise protocol consisting of high-load strength training, performed every second day, resulted in a superior outcome at 3 months compared with plantar specific stretching and may aid in a quicker reduction in pain and improvement in function’. However there was no significant difference between high load strength training and stretching at 6 and 12 months.

High-load strength training consists of single leg heel-raises with a towel inserted under the toes to further activate the Plantar Fascia and windlass-mechanism.

The towel is individualised by your physiotherapist/podiatrist, to ensure appropriate loading of the Plantar Fascia. The exercises are performed every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). This exercise will be specifically prescribed by your physiotherapist or podiatrist and will include a specific number of sets, repetitions and load.

Additionally, through your biomechanics assessment your physiotherapist or podiatrist may have highlighted altered lower limb biomechanics, including poor foot control and intrinsic foot strength, poor hip and lumbo-pelvic control. Exercises may also be included to help address these factors in the form of a home based program, gym based program or supervised clinical pilates program with our experienced Clinical Pilates instructors.

Stretching:

Calf muscle stretching is frequently prescribed for CPHP.

Specific stretching the plantar fascia for CPHP has been shown to be more effective than traditional weight bearing calf stretching. Three randomised controlled trials have now shown the effectiveness of plantar fascial stretching (Rompe 2010, DiGiovanni 2006, DiGiovanni 2003). It must therefore now be concluded that specific stretching of the plantar fascia is an important part of treatment and is shown to have similar long term effects to high load strength training.

The technique is simple and involves pulling the big toe toward the head for a stretch count of 30 and is demonstrated in this photo. A specific stretching protocol will be discussed with you by your treating practitioner.

Other treatment strategies and techniques that your Physiotherapist, Podiatrist or Myotherapist may utilise include: Soft Tissue and Trigger point releases and Dry Needling, ankle joint, mid-foot and toe mobilisations: (Talo-Crural, Sub-Talar and MTP joints).

Other treatment treatment techniques described in the research and used more in chronic cases (symptoms lasting 6 months or longer) are as follows:

-Extracorporeal Shock wave therapy (ECSWT)

-Cortico-steriod injection therapy

-Platelet Rich Plasma Infiltration

These and the above mentioned treatment options will be discussed in detail during your consultation with a Recover Sports Medicine practitioner and the most appropriate evidence based treatment applied.

Take home messages:

-Early protection and pain relief: It is important that you decrease or avoid activities that cause your heel pain to increase.

-Consult with a physiotherapist or podiatrist to accurately diagnose your condition and to identify the cause and aggravating factors and to prescribe a thorough treatment plan.

-For the athlete and runner, shoe selection is very important. It seems recommending minimalist footwear (4mm Heel drop or less), may be counterproductive given the increased ankle joint moment and eccentric load on the Achilles tendon and Plantar Fascia. Some arch support may be beneficial, and it seems clear cushioning will be important in this condition.

-For those keen on barefoot and minimalist running, very careful transition back to this style of running after complete symptom resolution is recommended.


Scott Hancock
Senior Physiotherapist
Recover Sports Medicine

If you have any questions regarding this post, or wish to book in to see our Physiotherapists, please call us on 1300 858 774 or email contact@recoversportsmed.com.au

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